Making the Case for More Specialist Training

Experts have reported that population growth among the elderly and the increasing prevalence of chronic diseases in these older Americans will have profound implications for the United States healthcare system in the coming decades. An estimated 89 million Americans will be 65 and older by 2050, a figure that is more than double the current population for this age group. In addition, more than 90% of elderly Americans report having one or more chronic diseases. “This trend is likely to continue,” says Timothy M. Dall, MS. “It will be challenging for the medical community to overcome the combination of increased longevity and high rates of chronic diseases like hypertension, diabetes, and obesity.”

Primary care physicians (PCPs) play an important role in providing preventive services and caring for the elderly population, but recent data suggest that the need for specialist care is also likely to increase as medical knowledge and treatment options continue to advance. “Specialists play essential roles in diagnosing, treating, and monitoring patients with various health problems,” says Dall. “Understanding the needs and demand for both primary care and specialist services can help inform decisions about the number and mix of healthcare providers that the U.S. will need to train so that care is accessible, of high quality, and affordable.”

Forecasting the Future

In a study published in Health Affairs, Dall and colleagues forecasted future demand for healthcare services and providers. This forecast was based on projected changes in demographic characteristics and other predictors of healthcare use as well as the estimated impact of expanded medical coverage under the Affordable Care Act. According to the analysis, growth and aging of the elderly population will be accompanied by a higher prevalence of many chronic diseases and medical conditions (Figure 1). For example, the rates of cardiovascular disease, stroke, and diabetes are projected to increase by more than 20% between 2013 and 2025.

The projected growth in specialty service demand between 2013 and 2025 also appears to be substantial, according to the Health Affairs study. The number of cardiology and rheumatology office visits, for example, is projected to increase by 18%. Urology, neurology, and dermatology visits are also projected to increase significantly (Figure 2).

“A large and diverse healthcare workforce is needed to effectively and efficiently diagnose and treat patients with complex medical conditions.”

Reflecting the more complex healthcare needs of the growing elderly population and their higher rates of hospitalization and surgery, inpatient hospital days are projected to increase by about 19% between 2013 and 2025. If these patterns do not change, specialties forecasted to see the largest increases in demand between 2013 and 2025 are vascular surgery (31%), cardiology (20%), and neurological surgery (18%). The demand for PCPs would grow by approximately 14% between 2013 and 2025 (Figure 3).

“Our projections of the increased demand for healthcare services and physicians reflect what will likely occur in the absence of paradigm shifts in the use and delivery of care,” says Dall. “Medical and technological advances may potentially change utilization and delivery patterns of care for patients with certain types of medical conditions. However, these advances may also increase the demand for services and providers from specialists.”

Meeting Increased Demand

One strategy to help meet the demand for primary care specialty services is to expand the scope of practice of allied health professionals. “It’s possible that some services currently requiring a physician’s supervision can be safely performed by non-physicians like physician assistants and nurse practitioners,” Dall says. “Such an approach could increase referral rates to specialists, which may enable highly trained specialists to focus on more clinically complex services and procedures.” He adds that managed care organizations, accountable care organizations, and patient-centered medical homes may help shift the delivery of care from specialists to primary care and allied health professionals. These organizations may also shift care delivery from EDs and hospitals to more appropriate outpatient settings.

There is ongoing debate about the number of specialists required to provide appropriate care for the U.S. population. “There are some indications that the supply of providers in many specialties is inadequate to meet the demand for services for both elderly and pediatric populations,” says Dall. “For example, patients often experience long wait times to see specialists, but research suggests that the same is also true in primary care. As such, a large and diverse healthcare workforce is needed to effectively and efficiently diagnose and treat patients with complex medical conditions.”

Specialization in medicine has expanded treatment options and provided physicians with the volume of cases to remain proficient in their area of expertise. The management of the country’s growing burden of chronic disease will likely require multidisciplinary teams, says Dall. “Our research indicates that specialists should be a key component of these teams and that their roles will need to be clearly defined as a part of patient care. The key is to train enough specialists so that we can avoid already long wait times, reduce access to care issues, and increase patients’ quality of life.”

Heidenreich PA, Trogdon JG, Khavjou OA, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123:933-944.

2 Comments

With inpatient hospital days projected to increase by about 19%, it seems natural that demand for hospitalists will increase. Some believe their role will continue to evolve to manage a team able to shift care delivery and integrate completely seamlessly with the outpatient setting.